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Monroe

The Monroe NOCN is limited to Monroe County and includes the largest urban center in our region, the City of Rochester. Monroe County is our region’s most densely populated area with 1,132 people per square miles of land area. Approximately one-half of the FLPPS Partnership is located in the Monroe NOCN.

Regional Snapshot

Number of Health Care Resources by County (2012)

County	Ambulatory Surgery Centers	Urgent Care Centers	# Nursing Home Beds	# Acute Care Beds	FQHCs	Assisted Living Facilities
Monroe	11	21	5244	2015	36	33

Data sources: FLHSA surveys, NYS Cost reports

Availability of Providers by Licensure Type per 100,000 population (2010)

County	All physicians	PCP	All other specialties	Dentists	Pharmacists	PA/NP
Monroe	377.6	139.9	237.6	76.7	99.9	200.7

Data source: Center for health workforce studies

Quick Reference

Lead Contact

Name:	Erin Bankey
Title:	DSRIP Operations Manager
Email:	Erin_Bankey@flpps.org
Phone:	585-239-9347

Workgroup Members

William Belecz, Trillium Health
Christopher Bell, Monroe County Medical Society
Michelle Boyd, University of Rochester Medical Center
Jordan Brown, Lifetime Assistance
Mark Curletta, CDS Monarch
Michelle Delzell, Upstate Home Care
Marisa Geitner, Heritage Christian Services
Adele Gorges, Health Homes of Upstate NY
Gary Griffin, Monroe Community Hospital
Michele Hannagan, Jordan Health
Janice Harbin DDS, Jordan Health
Kim Hess, Monroe Plan
Lawana Jones, The Autism Council
James Kennedy, Catholic Charities Community Servies
Christopher Kirisits, NYS Office of Mental Health
Michelle Lawrence, University of Rochester Medical Center
Robert Lebman, Loyola Recovery
Helen Lopez, Rochester Regional Health System
William McDonald, United Way
Christian Oleck, Planned Parenthood
Wendy Parisi, University of Rochester Medical Center
Kathy Parrinello, University of Rochester Medical Center
Deborah Peartree, Greater Rochester Health Home Network
Tiffany Pulcino MD, University of Rochester Medical Center
Katie Serio, Huther Doyle
Andrea Strecker, Rochester Regional Health System
Lori VanAuken, Catholic Charities Community Services
Theresa Villareale, Rochester Regional Health System
Kirk Vincent, Lifetime Care Home Health & Hospice
Barbara Wale, Arc of Monroe
Peg Warrick, Rochester Regional Health System
Bridgette Wiefling MD, Rochester Regional Health System
Tricia Williams, Monroe Arc
Sylvester Zielinski, CDC Monarch

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Regional Projects & Clinical Initiatives

CBO VBO Readiness Pilot

(January 2018 - March 2019) Education & training to prepare agency partners to participate in the future state of value-based contracting.

Participating Partners include ABC, Baden Street Settlement, Charles Settlement House, Catholic Family Center, Community Place of Greater Rochester, Foodlink, Ibero American Action League, The Center for Youth Services, The Salvation Army, and Rochester Rehab

Community Crisis Stabilization

(May 2018 - April 2019) Gap closure and service expansion of central triage, mobile crisis services, and crisis beds/residence specific to NOCN community needs.

Participating partners include Goodwill of the Finger Lakes, providing central triage for Monroe and Livingston counties as well as the entire Finger Lakes NOCN

Health Home Pilot

(April 2018 - Marc 2019) A Health Home/CMA pilot that reduces a care manager's case load with the goals of increased focus on comprehensive transitional care as well as preventive care for high risk patients.

Participating partners include Jordan Health, Rochester Regional Health, and UR Medicine

Innovation Fund (DY3)

(January 2018 - December 2018) Proposed solutions to improve performance on prioritized FLPPS P4P clinical outcomes intended to drive rapid results.

Projects and participating partners include:

Jordan Health - Increase pediatric Immunizations and lead screenings. Link children to primary care in a patient-centered medical home. Partnering with Rochester City School District

Trillium Health - Identify their high-risk, high-utilizing patients in real time, and more effectively develop and direct appropriate services and interventions for these patients at their moment of need. Develop and maintain effective Coaching for Activation in all direct care staff

Villa of Hope - Providing SUD Treatment. Intervention, prevention, and psycho-education to all youth, ages 13 and older, whose assessments indicate a need for intervention or SUD treatment

RGRTA - Transportation intervention pilot to test the value of a “mobility management system” for patients with transportation barriers, linking them to the most appropriate services. Partnering with Jordan Health, Monroe County Nurse Family Partnership/URMC VNS, Finger Lakes Community Health, Pembroke Family Medicine, Oak Orchard Health

His Branches, Inc. - 1) Improve the PCP experience with patients who overuse the ED, and build a stronger relationship with these patients to increase awareness and personal health management 2) Remove barriers to lab/diagnostic services that are most commonly needed but typically not accessed by patients

Lifespan - Develop community-based healthcare navigation services to assist adults, ages 65 +, with insurance eligibility and access to preventive care

Catholic Charities Community Services - Improve workflows that guide the delivery of services to the People Living with HIV/AIDS population

NOCN Initiatives

(July 2018 - June 2019) Proposed solutions and identified interventions to address key under-performing clinical outcomes specific to NOCN communities.

Projects and participating partners include:

MC Collaborative – Homeless Outreach and Peer Support Program introducing engagement specialists to provide training and outreach, while facilitating connections to Health Homes and Behavioral Health services

Recovery Coach University – Peer Recovery Coach Training in Monroe County. After completion of training, coaches are be assigned to specific service providers and to support patients with substance use disorder

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